A 52-year-old developmentally challenged woman, obese and with sleep apnea has the following ECG:

• Sinus rhythm
• Right atrial enlargement (tall positive component of the P wave in V1)
• Right axis deviation
• Right ventricular hypertrophy with repolarization abnormality

5 year ago this lady had been proven to have pulmonary hypertension (PA pressure 100 mm). Her condition has since deteriorated, and at the time of recording of this ECG tracing she was admitted in right heart failure.